Stress fracture of the acromion

Management of Extra-articular Scapular Fractures: A Narrative Review and Proposal of a Treatment Algorithm

The management of scapular fractures can be either conservative or operative, but it is still unclear how to choose the treatment option. Scapular fractures can be classified anatomically into four types: scapular spine, scapular body, and scapular neck where the treatment is conservative most of the time except for certain indications that are specific to each one, and inferior angle of the scapula where the operative treatment yields the best results but conservative treatment can be contemplated in some cases.

Nonunion of the so-called acromion: a systematic review with consideration of the terminology

INTRODUCTION

There is no widely accepted standard for the classification and treatment of traumatic acromion/scapular spine fracture nonunion due to the scarcity of this condition and the confusion of terminology.

MATERIALS AND METHODS

PubMed and Scopus were searched using "scapular fracture" and "acromion fracture" or "scapular spine fracture" as search terms. The inclusion criteria were English full-text articles concerning acromion/scapular spine fracture nonunion that described patient characteristics and presented appropriate images. The exclusion criteria were cases without appropriate images. Citation tracking was conducted to find additional articles and notable full-text articles written in other languages. Fractures were classified using our newly proposed classification system.

RESULTS

Twenty-nine patients (19 men, 10 women) with 29 nonunions were identified. There were four type I, 15 type II, and 10 type III fracture nonunions. Only 11 fractures were isolated. The mean period from initial injury to final diagnosis was 35.2 ± 73.2 months (range 3-360 months) (n = 25). The most frequent cause of delayed diagnosis was conservative treatment for fracture in 11 patients, followed by oversight by the physician in 8. The most common reason for seeking medical advice was shoulder pain. Six patients received conservative therapy, and 23 received operative treatment. Fixation materials included various plates in 15 patients, and tension band wiring in 5. Bone grafting was performed in 16 patients (73%, 16/22). Of the 19 surgically treated patients with adequate follow-up, the outcome was rated excellent in 79%.

CONCLUSIONS

Isolated acromion/scapular spine fracture nonunion is rare. Fracture type II and III, arising in the anatomical scapular spine, accounted for 86% of the fractures. Computed tomography is required to prevent fracture oversight. Surgical therapy produces good stable results. However, it is important to select the appropriate surgical fixation method and material after considering the anatomical characteristics of the fracture and stress on the fractured portion.

LEVEL OF EVIDENCE

V.

Scapular Stress Fracture of the Inferior Angle in an Adolescent Swimmer

We present the case of a competitive swimmer who was 14 years, 9 months old and had a 4-month history of posterior shoulder pain. She was initially evaluated by her school's trainer and completed a 2-week rehabilitation program, but pain returned with return to swimming. After feeling a "pop" while swimming with an increase in associated shoulder pain, the patient presented for medical evaluation. Plain radiographs were read as unremarkable. A formal physical therapy program resulted in increased pain, and the patient returned to clinic within 2 weeks with pain out of proportion to examination. Magnetic resonance imaging at this time identified a stress fracture along the inferior angle of the scapula, prompting a complete shutdown of activity for 4 weeks with vitamin D and calcium supplementation. A physical therapy regimen was restarted at 6 weeks with complete resolution of symptoms and return to swimming at 3 months. This case report is important because it highlights a sports-related stress fracture of the inferior angle of the scapula, a finding not currently present in the literature, in a swimmer, a sport not yet associated with scapular stress fractures. [Orthopedics. 202x(xx):xx-xx.].

History of diagnostics and treatment of scapular fractures in children and adolescents and its clinical importance

Almost 70 scapular fractures in children and adolescents, up to the age of 17 years, have been described in detail in the literature since 1839. The diagnosis of these injuries was based on autopsy, radiographs, CT and MRI examinations. The most frequent findings were fractures/epiphyseolyses of the coracoid, followed by fractures of the infraspinous part of the body and avulsion of the inferior angle of the scapular body. Less common were fractures of the acromion. Intra-articular fractures of the glenoid, or separation of an intact glenoid along the line of the anatomical or surgical necks, were reported only sporadically. Scapulothoracic dissociation was also recorded in several cases. The majority of fractures were treated non-operatively; operative treatment was used in glenoid fractures, certain fractures of the coracoid and fractures of the scapular body with intrathoracic penetration. Except for scapulothoracic dissociation, outcomes of treatment of these injuries were very good.

Diagnosis and Treatment of Scapular Fractures in Children and Adolescents: A Critical Analysis Review

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Fractures of the growing scapula account for about 0.1% of all pediatric fractures, with the majority occurring at an age of ≥10 years.

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Radiographic diagnosis requires a detailed knowledge of the ossification sequence of the growing scapula. Computed tomography examination is indicated for displaced fractures of the glenoid fossa, the scapular neck, and complex fractures; magnetic resonance imaging should be performed in cases of suspected injury to the physis and with stress fractures, depending on patient age and the potential need for general anesthesia during the scanning process.

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Separation of the base of the coracoid process is often associated with acromioclavicular dislocation. Clavicular fractures rarely occur in combination with injuries to the growing scapula.

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The majority of scapular fractures can be treated nonoperatively. Indications for surgery are displaced intra-articular fractures, scapular neck fractures with a displacement of >2 cm, coracoid base separation associated with acromioclavicular dislocation, and scapulothoracic dissociation.

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Displaced intra-articular fractures of the glenoid fossa should be followed after healing until skeletal maturity. Complications are rare and occur most frequently with scapulothoracic dissociation.

Isolated Acromial Fracture in a Cyclist: A Case Report and Review of the Literature

CASE

An isolated acromial fracture was diagnosed in a 45-year-old subject, recreational athlete, during a cycling fall on the shoulder. Clinical examination combined with x-ray and computerized tomography scan confirmed the isolated injury. Open reduction and osteosynthesis using a tension band technique was performed. The patient was immobilized in a sling for 6 weeks, and fixation hardware was removed after 6 months. At the 1-year follow-up, patient had returned to his preinjury level of athletic activity.

CONCLUSION

Isolated acromial fracture is an uncommon sports-related injury. Although several treatment modalities exist, nonoperative, immobilization treatment is typically effective if fracture is not displaced. Osteosynthesis should be considered if there is subacromial impingement or fracture displacement >10 mm.

Postoperative results of Ogawa type IIB meta-acromion fracture fixation with a 90° twisted reconstruction plate

INTRODUCTION

Acromion fractures are rare and difficult to treat. There is no consensus on type of fixation. Due to the rarity of the injury, it is difficult to compare different techniques of osteosynthesis.

OBJECTIVES

The aim of this study was to present the long-term results of an alternative method of plating Ogawa type IIB meta-acromion fractures and to review the literature.

DESIGN

Retrospective study.

MATERIALS AND METHODS

We present a case series of 11 consecutive patients with displaced Ogawa type IIB meta-acromion fracture, treated with open reduction internal fixation using a 3.5-mm contoured pelvic reconstruction plate with a 90° twist. Patients' mean age was 53.3 years (23-80 years) and the mean follow-up was 48.3 months (15 months-9 years). The outcomes related to pain and shoulder function were evaluated by Modified American Shoulder and Elbow Surgeons Score (ASES) and SF-36 score. All patients were asked about their satisfaction level.

RESULTS

Nine out of eleven patients were included in this study. Eight of them obtained union and all were satisfied with the final outcome. The mean ASES and SF-36 score were 69.75 (42.4-98.14) and 61.37 (41.64-94.99), respectively, with poor scores to be largely associated with comorbidities and concomitant injuries.

CONCLUSIONS

The use of 3.5-mm reconstruction plate with a 90° twist for open reduction internal fixation (ORIF) of meta-acromion fractures presents satisfactory results and could be technically a more stable biomechanical construct in comparison to the existing surgical techniques.

The traumatic acromion fracture: review of the literature, clinical examples and proposal of a treatment algorithm

PURPOSE

Traumatic acromion fractures are rare and typically occur in patients with multiple fractures, which often delays diagnosis. Limited guidance exists on the treatment of these fractures. We present a review of the literature from the last 20 years and describe our experience in treating five patients-two conservatively and three with open reduction and internal fixations (ORIF).

METHODS

We used the U.S. National Library of Science database, MEDLINE^®, to search for all pertinent publications from January 1999 to December 2017. Included were retrospective or prospective studies, including case series and case reports, describing treatment for traumatic acromion fractures and clinical and/or radiological outcomes. For our case reports, we present five patients with traumatic acromion fractures who were treated at our institution between 2013 and 2017.

RESULTS

Through our review of 14 publications, we found that current recommendations are often based on a limited number of cases. No gold standard to treat these fractures exists. Most authors recommend anatomic reconstruction, especially for dislocated fractures, persistent symptomatic non-unions or additional injuries to the superior shoulder suspensory complex. There is no clear trend in terms of the operative technique. With regard to our five clinical examples that were all initially treated conservatively, two were successful and three eventually required reconstruction with ORIF. Based on the findings of this review, we proposed a treatment algorithm for traumatic acromion fractures.

CONCLUSIONS

A classification system providing clear guidance on treatment options is needed. Although the non-union rate with conservative treatment is relatively high, it is not always painful or limiting to shoulder function, especially in elderly or less active patients. Fixation seems to be a more suitable treatment option for active patients who are more likely to require revision of symptomatic non-unions.

A stress fracture of the base of the acromion: a case report

Background

Stress fractures of the base of the acromion are rare and tend to progress well when conservatively treated. The need for surgery due to this type of fracture has only been reported in two case reports.

Case presentation

A 39-year-old patient, manual laborer, with a stress fracture at the base of the acromion that required surgical treatment due to persistent symptoms and consolidation failure.

Conclusion

We described a new mechanism of injury for stress fractures of the base of the acromion. After the failure of conservative treatment, the patient exhibited good results with osteosynthesis with a plate and screws, with no need for a bone graft.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-302) contains supplementary material, which is available to authorized users.

Surgical management of isolated acromion fractures: technical tricks and clinical experience

Acromion fractures of the scapula are rare and most often occur with concomitant fractures of the ipsilateral glenoid, neck and body of the scapula as sequelae of high-energy injuries. Indications for operative management include symptomatic nonunion, displaced fractures, or acromion fractures associated with other lesions of the superior shoulder suspensory complex. Less displaced acromion fractures resulting in decreased subacromial space may also warrant surgery. Although surgical indications have been reported, the literature regarding surgical approaches and fixation techniques for management of these factures is limited. Acromion fractures can generally be addressed with a direct posterior approach using either tension band or low-profile plating in combination with cortical lag screws to obtain a stable construct. This technique is both effective in achieving fracture union and safe to the patient. When associated with a more complex fracture of the glenoid and/or scapula body, the surgical approach and fixation strategy should be dictated by the optimal approach to other displaced elements of a scapula fracture. The purpose of this study was to describe a step-wise approach to the surgical management of isolated acromion fractures, describe surgical tips and techniques, and to present the early clinical outcomes in 13 patients after surgical treatment with this approach.

Surgery for scapula process fractures: good outcome in 26 patients

BACKGROUND

Generally, scapula process fractures (coracoid and acromion) have been treated nonoperatively with favorable outcome, with the exception of widely displaced fractures. Very little has been published, however, regarding the operative management of such fractures and the literature that is available involves very few patients. Our hypothesis was that operative treatment of displaced acromion and coracoid fractures is a safe and effective treatment that yields favorable surgical results.

METHODS

We reviewed 26 consecutive patients (27 fractures) treated between 1998 and 2007. Operative indications for these process fractures included either a painful nonunion, a concomitant ipsilateral operative scapula fracture, > or = 1 cm of displacement on X-ray, or a multiple disruption of the superior shoulder suspensory complex. All patients were followed until they were asymptomatic, displayed radiographic fracture union, and had recovered full motion with no pain.

PATIENTS AND RESULTS

21 males and 5 females, mean age 36 (18-67) years, were included in the study. 18 patients had more than one indication for surgery. Of the 27 fractures, there were 13 acromion fractures and 14 coracoid fractures. 1 patient was treated for both a coracoid and an acromion fracture. Fracture patterns for the acromion included 6 acromion base fractures and 7 fractures distal to the base. Coracoid fracture patterns included 11 coracoid base fractures and 3 fractures distal to the base. Mean follow-up was 11 (2-42) months. All fractures united and all patients had recovered full motion with no pain at the time of final follow-up. 3 patients underwent removal of hardware due to irritation from hardware components that were too prominent. There were no other complications.

INTERPRETATION

While most acromion and coracoid fractures can be treated nonoperatively with satisfactory results, operative management may be indicated for displaced fractures and double lesions of the superior shoulder suspensory complex.

Open reduction internal fixation after displacement of a previously nondisplaced acromial fracture in a multiply injured patient: case report and review of literature

SUMMARY

A twenty-eight-year-old multiple trauma patient had a nondisplaced acromion fracture that was not detected until after it had displaced. Open reduction internal fixation was performed without complication and the patient achieved excellent shoulder abduction strength. Nondisplaced acromion fractures may displace if not protected. Open reduction internal fixation of displaced acromion fractures should be considered if deltoid muscle strength is important to the patient.

Comparison of arthroscopic and open anterior shoulder stabilization. A two to six-year follow-up study

BACKGROUND

Sixty-three consecutive patients with recurrent traumatic anterior shoulder instability underwent operative repair. The decision to select either arthroscopic Bankart repair or open capsular shift was based on the findings of an examination under anesthesia and the findings at the time of arthroscopy. Thirty-nine patients with only anterior translation on examination under anesthesia and a discrete Bankart lesion underwent arthroscopic Bankart repair with use of absorbable transfixing implants. Twenty-four patients with inferior translation in addition to anterior translation on examination under anesthesia and capsular laxity or injury on arthroscopy underwent an open capsular shift.

METHODS

Treatment outcomes for each group were determined according to the scoring systems of Rowe et al., the American Shoulder and Elbow Surgeons, and the Short Form-36. Failure was defined as recurrence of dislocation or subluxation or the finding of apprehension. Fifty-nine (94 percent) of the sixty-three patients were examined and filled out a questionnaire at a mean of fifty-four months (range, twenty-seven to seventy-two months) following surgery.

RESULTS

There were no significant differences between the two groups with regard to the prevalence of failure or any of the other measured parameters of outcome. An unsatisfactory outcome occurred after nine (24 percent) of thirty-seven arthroscopic repairs and after four (18 percent) of twenty-two open reconstructions. All cases of recurrent instability resulted from a reinjury in a contact sport or a fall less than two years postoperatively. The treatment groups did not differ with regard to patient age, hand dominance, mechanism of initial injury, duration of follow-up, or delay until surgery. Measured losses of motion were minimal and, with the exception of forward elevation, slightly more of which was lost after the open capsular shifts (p = 0.05), did not differ between the two forms of treatment. Approximately 75 percent of the patients in each group returned to their favorite recreational sports with no or mild limitations. As rated by the patients, the result was good or excellent after thirty-one (84 percent) of the arthroscopic procedures and after twenty (91 percent) of the open procedures.

CONCLUSIONS

Arthroscopic and open repair techniques for the treatment of recurrent traumatic shoulder instability yield comparable results if the procedure is selected on the basis of the pathological findings at the time of surgery.